ANESTH ANALG LETIERS TO THE EDITOR 851

1995;80:848-57

References
1. US General Accounting Office Report GAO/HRD 92-110. Prescription drugs: compa-
General Anesthesia and Preterm
nies typically charge more in the United States than in Canada; Sept 1992.
2. US General Accounting Office Report GAO/HEHS-94-29. Prescription drugs: compa-
Neonatal Outcome
nies typically charge more in the United States than in the United Kingdom; Jan 1994. To the Editor:
3. Pear R. Report finds prescription drugs cost more in US than in Britain. New York
Times 1994 Feb 22;Sect. A:9. The study by Rolbin et al. (1) on the association of anesthetic
technique with preterm neonatal outcome at cesarean section does
not surprise us, in that the use of general anesthesia resulted in a
greater percentage of low Apgar scores. We were astonished, how-
ever, to read that factors such as “placental or cord problems and
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fetal distress were not associated with an increased risk of low

Apgar scores.” Information presented in Table 2 states that, of a
Alfentanil and Retrobulbar Nerve Block total of 509 patients in the study, 81 had placental or cord problems,
To the Editor: and 121 exhibited fetal distress. We are also told that the “propor-
tion of infants with placental or cord problems, or fetal distress, was,
We read with interest the study by Yee et al. (1) comparing patient
in fact, similar in the general anesthesia and epidural groups.” We
movement during retrobulbar block placement with methohexital
would like to raise the possibility that since the terms “cord prob-
or alfentanil administration. Although we too have found alfentanil
lem, placental problem, and fetal distress” are imprecise, more
to be useful for this purpose, two questions are raised.
exacting definitions could have altered the results. If the term “fetal
No mention was made of the needle used. As the 23-gauge
distress,” for example, were limited to those fetal heart rate patterns
Atkinson needle (Visitecm, Sarasota, FL) produces a greater stimulus
of sufficient severity so as to place the fetus in immediate danger of
on skin penetration compared with local infiltration and advance of
asphyxial damage (2), such as profound decelerations with absent
a smaller, sharper needle, the choice of needle influences alfentanil
variability, or prolonged bradycardia (21, then one might have had
dose titration. The elderly ophthalmic surgical population is usually
a much smaller, but more significant, sample size of neonatal factors
more sensitive to respiratory and cardiovascular depressant effects
associated with low Apgar score. If the fetus is in immediate jeop-
of alfentanil, and we are surprised that the 1500 pg used in the series
ardy, however, cesarean section is usually not delayed to establish
(20 pg/kg x weight) did not have significant respiratory depression
an adequate sensory level with spinal or epidural block (3). In the
and that no mention was made of hemodynamic variables.
present study, where the anesthetic technique was not randomized,
We have achieved satisfactory patient comfort and tolerance of
the tendency for the anesthesiologist to exhibit a selection bias
the block without significant respiratory or cardiovascular compro-
toward general anesthesia in such a situation of fetal jeopardy could
mise with titration of 250- to 750-pg doses of alfentanil (5-10
be strong indeed.
pg/kg). Contrary to the concern of patient movement causing com-
plications, earlier awakening with smaller doses of an anesthetic or Harold J. Heyman, MD
opioid would assist in differentiating problems such as brainstem Ninos J. Joseph, BS
anesthesia or pain from retrobulbar hemorrhage. Department ofAnesthesiology
Zllinois Masonic Medical Center
E. G. Eivalizza, MBChB, FFA Chicago, IL 60657
D. C. Abramson, MBChB, FFA
Department ofAnesthesiology References
1. Rolbin SH, Cohen MM, Levinton CM, et al. The premahlre infant: anesthesia for
Medical School cesarean delivery. Anesth Analg 1994;78:912-7.
The University of Texas Health Science Center at Houston 2. Parer JT. Diagnosis and management of fetal asphyxia. In: Shnider SM. Levinson G, eds.
Houston, TX 77030 Anesthesia for obstetrics. Baltimore: Williams & Wilkins, 1993657-70.
3. Shnider SM, Levinson G. Anesthesia for cesarean section. In: Shnider SM, Levinson G,
Reference eds. Anesthesia for obstetrics. Baltimore: Williams & Wilkins, 1993211-45.
1. Yee JB, Schafer PG, Crandall AS, Pace NL. Comparison of methohexital and alfentanil
on movement during placement of retrobulbar nerve block. Anesth Analg 1994;79:
3203.
In Response: We asked Dr. Cohen for a response but failed to obtain one.
We thank Drs. Pivalizza and Abramson for sharing their experience
regarding the use of alfentanil in patients undergoing placement of
retrobulbar block. They bring up two interesting points in their
letter. First, the needle used for placement of all the blocks in our
study was a 23-gauge Atkinson needle. This may account for the Pediatric Liver Transplantation
lower dose of alfentanil that they find effective in their patient
population. The dose of alfentanil (20 pg/kg) that we used in our To the Editor:
study was selected based upon our clinical experience here at the There are three points we would add to the excellent review article
University of Utah using this needle. However, the absence of a by Carton et al. (1,2).
dose-response curve is a major limitation of our study, as was noted The first deals with the differences between adult and infant
in our Discussion section. To address this important question, we coagulation. Normal adult levels of vitamin K-dependent clotting
are presently conducting a study looking at the dose response to factors may not be reached for several weeks in the normal neonate.
alfentanil and propofol. It is true that the older population is more During the first few days of life, the already decreased levels of
sensitive to the respiratory and cardiovascular depressant effects of factors VII, IX, and X and prothrombin become progressively lower,
opioids, and, as we reported, one patient did develop significant and this decrease can be prevented by administering vitamin K (3).
respiratory depression. However, in our further clinical experience, Other vitamin K-dependent proteins synthesized by the liver in-
this appears to be an uncommon and easily handled problem. Early clude proteins C and S. Protein C inhibits the function of factors VIII
awakening has not been a problem with this dose of alfentanil (20 and V and enhances fibrinolysis; these properties are enhanced by
pg/kg) because the vast majority of patients are alert and oriented protein S. Protein C is significantly reduced in plasma from healthy,
during the placement of the block. full-term, newborn infants and remains below levels found in serum
from adults for at least 6 mo (4). Protein S concentrations are
James B. Yee, MD, PhD reduced but increase to within the range found in normal adult
Department ofAnesthesiology plasma by 3 mo of age (5).
The University of Utah
Salt Lake City, UT 84132 The second deals with the hypercoagulable state seen postoper-
atively. After liver transplantation in children, a decrease occurs in
the plasma concentrations of both protein C and antithrombin III to